Use this URL to cite or link to this record in EThOS: http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.726454
Title: Chronic childhood constipation : novel approaches to diagnosis and management
Author: Clarke, Melanie C. C.
Awarding Body: University of Edinburgh
Current Institution: University of Edinburgh
Date of Award: 2011
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Abstract:
Introduction: This thesis describes the aetiology, pathology, diagnosis and management of children with constipation. In particular, it describes a condition, slow transit constipation, which represents a form of chronic childhood constipation that is not readily responsive to conventional treatment. Hypothesis and aims: Firstly this thesis hypothesises that quality of life is affected by slow transit constipation when subjects are compared to healthy age matched controls. Secondly, it proposes to ascertain whether or not nuclear scintigraphy represents a reliable means of assessing colonic motility. Thirdly, it seeks to determine whether or not transcutaneous electrical stimulation (in the form of interferential therapy) has the ability to alter either the clinical symptoms, quality of life or colonic transit of children with slow transit constipation. Lastly, this thesis aims to look at a subgroup of children with slow transit constipation managed by antegrade continence enemas delivered via an appendix stoma, and determine whether or not colonic activity, measured by a manometric catheter inserted via their appendicostomy, is affected by transcutaneous inferential therapy. Methods: Study 1 - Children (8-18yrs) with symptoms of constipation and proven slow transit constipation on nuclear scintigraphy, with symptoms for > 2years unresponsive to conventional dietary, medical and behavioural therapies, were recruited from gastrointestinal and surgical out-patient clinics. Control subjects were recruited from a local scout jamboree. QoL was assessed using the PedsQL tool that consists of parallel parent and child reported scores. Physical, psychosocial and total quality of life scores were compared using Wilcoxon matched pairs and Mann Whitney tests. Study 2 - Children (8-18yrs) with symptoms of constipation for > 2years unresponsive to conventional dietary, medical and behavioural therapies, who had had 2 nuclear transit studies performed on separate occasions were recruited from gastrointestinal and surgical out-patient clinics. Geometric centres of radioactivity were compared at 6, 24, 30 and 48hrs. The GC at each time point for the initial and repeat studies were compared by parametric statistical analysis (paired t-test). Study 3 - Children (8-18yrs) with symptoms of constipation and proven slow transit constipation on nuclear scintigraphy, with symptoms for > 2years unresponsive to conventional dietary, medical and behavioural therapies, were recruited from gastrointestinal and surgical out-patient clinics. Children were randomised to receive either real or placebo interferential therapy consisting of 12 treatment sessions over a 4 week period. Frequency of defecation, soiling and abdominal pain were assessed before, during and after intervention. Quality of life scores (PedsQL, Holschneider and Templeton) and gastrointestinal transit time (nuclear scintigraphy) were also evaluated before and after treatment. Data were analysed using independent sample and paired t tests. Where the data were not normally distributed, either Mann Whitney or Wilcoxon matched pairs testing was performed. Study 4 - Children (8-18yrs) with symptoms of constipation and proven slow transit constipation on nuclear scintigraphy, with symptoms for > 2years unresponsive to conventional dietary, medical and behavioural therapies, with pre-existing appendix stomas were recruited from gastrointestinal and surgical out-patient clinics. Subjects received the same intervention as described in study 3 with all participants receiving real interferential therapy. Colonic activity was assessed pre- and post-intervention by colonic manometry - the catheter having been inserted in an antegrade fashion via the appendicostomy. Data were analysed using paired t tests. Results: Study 1 - Subjects with slow transit constipation (n=51) described significantly poorer quality of life than age matched controls (n=79). This was so for total child reported (p = < 0.0001) and parent reported (p < 0.0001) scores. Reported scores for subjects with slow transit constipation were comparable to other chronic disease states. Study 2-7 children were recruited in whom 2 nuclear transit studies had been performed. There was no statistical difference between the 2 studies when comparing mean geometric centre of radioactivity at 6hrs (p = 0.161), 24hrs (p = 0.780), 30hrs (p = 0.947) and 48hrs (p = 0.615). Study 3-35 children were recruited, 18 of whom were randomised to receive real interferential therapy. There were no statistical differences between the 2 groups. There was no change in frequency of defecation or soiling. There was a small improvement in episodes of abdominal pain in the group that received real treatment (p = 0.05). There appeared to be a decrease in colonic transit time as measured by nuclear scintigraphy after intervention with real interferential therapy. There was a significant difference in the post-intervention GC between the 2 treatment arms at 24 (p = 0.004), 30 (p = 0.02) and 48 (p = 0.002) hours. Comparing the 2 treatment groups before and after intervention there was no change in quality of life scores. When looking at each individual treatment arm, children described a significant improvement in their quality of life (PedsQL scores) after real interferential therapy (p = 0.005). Study 4-5 children underwent colonic manometry before and after treatment with inferential therapy. There was a small increase in antegrade colonic activity following intervention p = 0.03. No other measured parameters were affected (amplitude, duration, velocity and regional linkage). There was no statistical difference in their frequency of episodes of defecation, soiling or abdominal pain. Conclusion This thesis concludes that quality of life is adversely affected by slow transit constipation and that evaluation of quality of life should be part of routine assessment of children with constipation. It also proposes that nuclear scintigraphy represents a reliable means of assessing colonic transit in states of colonic inertia such as slow transit constipation. Lastly, having demonstrated varied subjective and objective responses to its application, it proposes that further evaluation is required to evaluate the potential use of interferential therapy in children with slow transit constipation.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID: uk.bl.ethos.726454  DOI: Not available
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